A case of broncho-cutaneous fistula secondary to tuberculosis successfully managed with awake veno-venous extracorporeal membrane oxygenation

Abstract

A broncho-cutaneous fistula (BCF) is a communicating tract between the bronchus and the cutaneous surface of the thoracic wall and can be the primary presenting sign of several disease processes. It has been associated with positive pressure ventilation (PPV), post pneumonectomy, thoracostomy tubes, perforating chest trauma, neoplasia and chronic empyema. We report a case of a 45-year-old immunocompetent man presenting with severe hypercapnic respiratory failure secondary to a BCF as a result of tuberculosis (TB)-related empyema necessitans. Veno-venous extracorporeal membrane oxygenation (VV ECMO) was employed during spontaneous breathing to mitigate the risks of PPV, to facilitate diagnostics and enable targeted treatment. Awake VV ECMO is an effective supportive therapy for complex, destructive lung pathologies with a known reversible aetiology in which PPV would be potentially detrimental.

Keywords: Awake ECMO; Broncho-cutaneous fistula (BCF); Extra corporeal membrane oxygenation (ECMO); Positive pressure ventilation (PPV); Tuberculosis (TB).

Fig. 1

CT scan at tertiary centre. Cystic chances at apices and air noted in the right anterior chest wall.

Fig. 2

CT scan showing the defect in the right anteromedial chest wall.

Fig. 3

CT scan showing gas extending from pleural space to the right anteromedial chest wall.

Fig. 4

CT scan showing large gas-filled cavity overlying the subcutaneous tissues.

Fig. 5

Chest X-ray before intercostal chest drain insertion.

Fig. 6

Chest X-ray after intercostal chest drain insertion and drainage of empyema.

Fig. 7

Chest X-ray after removal of intercostal chest drain and decannulation from VV ECMO.